Answer to Question 1
C
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A Incorrect. Dehydration can lead to constipation and in extreme cases a bowel obstruction; however, this is not the nurse's priority because circulation issues take precedence over a potential gastrointestinal issue.
B Incorrect. Dehydration increases the risk of delirium, especially in a hospitalized patient, but this has a lower priority than a circulation issue.
C Correct. This older adult is at high risk for a thromboembolic event as a result of bed rest and dehydration. The nurse's priority is to prevent a thromboembolic event, including deep venous thrombosis and pulmonary embolism, because it is a potentially life-threatening situation. The patient is likely to have low circu-lating blood volume as evidenced by tachycardia, a compensatory mechanism when the tissues receive inadequate oxygenation. In addition, compensatory mechanisms that help to restore fluid balance are limited in an older adult. This results in poorer tissue perfusion and an increased risk for thrombus formation for a patient who is on bed rest, because a lack of skeletal muscle action pro-motes pooling of blood in the extremities.
D Incorrect. Dehydration increases the risk of delayed wound healing because op-timum wound healing occurs in a moist environment. However, this is a sec-ondary concern until the nurse manages the circulation issue.
Answer to Question 2
C
The nurse assesses an older adult who is exhibiting psychotic behavior by searching for a reason from a wide variety of potential causes for the behavior. For example, neuroleptic medications can cause extrapyramidal side effects, which can result in movement disorders that are similar to psychotic behavior.
Hallucinations in older patients are usually the result of physical disorders, dementias, or sensory function loss. A delusion is a belief that is maintained, although facts can prove that it is incorrect. A hallucination or illusion is the sensory perception of a stimulus that does not exist in the external world. Treatments for hallucinatory states vary according to the cause.
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